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    Fractioned laser benefits for skin resurfacing

    Fractioned laser systems for skin resurfacing can be separated into four categories — nonablative, microablative fractional, macroablative fractional and picosecond fractional — according to a presentation at October’s annual congress of The Dermatologic & Aesthetic Surgery International League (DASIL) in Dubai.

    “Having a range of options allows us to tailor treatment for the right indication,” says Vic A. Narurkar, M.D., director of the Bay Area Laser Institute in San Francisco. “This includes treating younger patients in a more preventive approach. Also, therapy-resistant melasma has some new alternatives. We can also now treat diverse skin types from I though VI.”

    However, how a fractioned laser is delivered is just as important as the technology itself, Dr. Narurkar tells Dermatology Times prior to his talk. “Delivery is either in a random scanning pattern or in a stamping pattern,” he says.

    Dr. Narurkar says the random scanning pattern tends to be more advantageous because it provides a more even delivery of laser with fewer complications. “This is because the fractionated dots are delivered sort of randomly, so there is more even distribution of the energy,” he says. “This is in contrast to the stamping mode, which is more dependent on the operator and thus can result in either skip areas or hot spots.”

    The general consensus is that the workhorse of most practices is a nonablative fractional laser, such as the Clear + Brilliant laser (Valeant Pharmaceuticals Int. Inc.) or the Fraxel ReStore laser (also from Valeant).

    “Nonablative treatment allows you to treat the widest range of skin types and the widest skin conditions, ranging from mild sun damage to acne scars to surgical scars, as well as general resurfacing both on the face and off the face,” says Dr. Narurkar, who favors the Fraxel ReStore laser. “This is one of the best investments we have made.”

    For patients with more severe sun damage, ablative fractional lasers are employed, with fractional CO2 lasers being the most popular.

    “You used to have to penetrate deeply with fractional CO2 lasers, but now we are finding that you do not have to go that deep to achieve great results,” Dr. Narurkar says. “Microablative lasers can produce pretty significant outcomes, while minimizing the risks of infection and hypertrophic scarring.”

    Microablative lasers are especially effective for wrinkles around the mouth and the eyes. “The healing is also much faster, usually between three to six days, as opposed to two weeks with standard ablative lasers,” Dr. Narurkar says.

    On the other hand, macroablative fractional lasers are suitable for very deep wrinkles and scars.

    The newest generation of fractionated lasers is the picosecond fractional laser, which incorporates laser-induced optical breakdown (LIOB), such as the PicoWay laser (Syneron-Candela). “Unlike previous lasers that are primarily photothermal, the main mechanism of a picosecond fractional laser is photoacoustics,” Dr. Narurkar says. “This is basically sound waves shattering holes in the dermis to promote new collagen.”

    The picosecond fractional laser is initially being used to treat facial and non-facial fine lines, scars and shows promise for treating therapy-resistant melasma using the 1064 nm Resolve handpiece. “There is very little recovery with this mode of treatment,” Dr. Narurkar says

    If a practice is comprised primarily of younger patients and ethnically diverse, Dr. Narurkar recommends a nonablative fractional laser for most procedures. But for practices with mostly older patients with a lot more sun damage and more lighter-skinned patients, better results will be achieved with microablative and macroablative lasers.

    Patient skin preparation before laser treatment is also key. “We use a variety of topical agents, such as vitamin C, retinol and sunscreen,” Dr. Narurkar says. “We also premedicate with oral valacyclovir (Valtrex) those patients who have a risk of herpes.”

    For patients with a history of post-inflammatory hyperpigmentation (PIH), Dr. Narurkar pre- and post-treats with lightening agents like non-hydroquinone and hydroquinone-containing agents.

    In addition, set realistic patient expectations.

    “Resurfacing is just one component of global rejuvenation,” Dr. Narurkar says. “You still need to add Botox and fillers to attain optimal cosmetic outcomes.”

    Going forward, Dr. Narurkar envisions cosmeceuticals and topical agents being delivered into the skin during laser treatment becoming increasingly popular.

    “We have already had some significant results when using the Clear + Brilliant laser in combination with topical vitamin C and lightening agents for melasma,” he says.


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